Contribute more to the health system by smoking? Five key concepts to better understand what is behind this debate
Laura van der Werf Paintings
In recent days we published a survey in which we asked if it would be fair for those who smoke to contribute more to the financing of the health system than those who do not. More generally, this question is about whether all members of society should finance the risks taken by those people who have habits that we now know increase the risk of disease. But what arguments are there for and against contributions to the health system being proportional to the risk taken?
Health insurance is a contract in which the insurer agrees to pay for the services required by the insured in case of illness, in exchange for a regular payment called a premium. The purpose of having health insurance is to financial protection, which consists of preventing direct payments to obtain health services from being so high in the event of illness that they can lead to serious financial difficulties that threaten their living standards (1).
Financial protection is important because it ensures that people have access to health services if they need them, regardless of whether or not they have the resources to pay for them directly, thus protecting the right to health.
Health insurance and risk behaviors
Insurance is possible because people's care costs are distributed asymmetrically. This means that most of the resources are spent to cover the costs generated by relatively few people, while the rest of them consume a much lower amount of resources. The problem, however, is that the expected expenditure is also distributed asymmetrically: it can be predicted that some people will consume more resources than others. For example, people who smoke are more likely to get sick more often or more seriously, or people who have chronic illnesses are more likely to consume more resources.
These differences in the probability of consuming resources lead to incentives to avoid insuring or charging a higher premium to those people who are at higher risk of becoming ill. These practices are known as risk selection and rating (2,3).
On the other hand, the fact that people are insured can promote behaviors that increase the risk of getting sick or using health services in an excessive way, by not having to fully cover the costs of using them. This is called moral hazard (4).
Why charge more to those who take more risks?
In our survey, the majority of people (75.6%) considered that it would be fair for people who smoke to contribute more to financing the health system. An argument used in favor is that these people must contribute more to the health system because of their bad habits, which in turn can discourage those bad habits.
The other argument that is used is that it is not fair that people who take fewer risks associated with negative consequences have to pay for people who take more of these types of risks. Behind this way of understanding justice is a principle called actuarial equity. According to this concept, people should pay proportionally to the risk to which they are exposed, since it is not considered fair that those who take less negative risks have to pay for those who take those risks more (5).
Why charge the same to those who take more risks?
Among those who consider that it is not fair that those who smoke have to contribute more to the financing of the health system, they argue that smoking is an addiction, that is, it is a disease over which people have no absolute control. In fact, only between 3 and 5% of patients manage to stop smoking autonomously, between 7 and 16% they achieve it with a behavioral intervention and around 24% they achieve it when they receive both drug treatment and behavioral interventions (6). It is difficult to define where the line should be drawn between risk factors over which people have control and over which people have no control. Would it be fair to charge a person more for being exposed to a risk factor over which they do not have control?
Another argument against contributions to the health system being proportional to risk is that this would make it difficult for the people who most need access to health services to access them. This has been described as the reverse care law, according to which the availability of good health coverage tends to vary inversely with the need for it (2). When access to insurance is more difficult for those most at risk of becoming ill, these individuals (and their families) are no longer financially protected.
The principle underlying payment not proportional to the risk of getting sick is the solidarity, more specifically risk solidarity. According to this principle, those people who are at low risk of getting sick should subsidize people who are at high risk of getting sick.
And in Colombia, how does this work?
Behind the way in which the health systems of each country are configured, there are principles that are considered more or less important in each one of them. While in countries like the United States, actuarial equity is considered a more important principle than risk solidarity, in many European countries risk solidarity prevails over actuarial equity.
In Colombia, within the principles of the General System of Social Security in Health is solidarity, defined as the practice of mutual support to guarantee access and sustainability to Social Security in Health services. There is also the principle of co-responsibility, according to which everyone must strive for their self-care, for the health care of their family and their community, a healthy environment, the rational and adequate use of the resources of the General System Social Security in Health and fulfill the duties of solidarity, participation and collaboration.
At least on paper, the predominant principle is solidarity, however, it is also sought that people take care of their own health and use health services appropriately. The health system needs to find ways to encourage self-care, without jeopardizing financial protection, access to health services and consequently the guarantee of the right to health. Soon on our blog we will be telling you more about issues related to promoting healthy habits through health policies.
1. QUIEN. WHO | Financial protection [Internet]. QUIEN. World Health Organization; 2018 [cited 2019 Mar 25]. Available from: https://www.who.int/health_financing/topics/financial-protection/en/
2. Light DW. The practice and ethics of risk-rated health insurance. JAMA. 1992 May; 267 (18): 2503–8.
3. Ellis RP, Fernandez JG. Risk selection, risk adjustment and choice: concepts and lessons from the Americas. Int J Environ Res Public Health [Internet]. 2013 Oct 25; 10 (11): 5299–332. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24284351
4. Donaldson C, Gerard K. Countering moral hazard in public and private health care systems: a review of recent evidence. J Soc Policy. 1989 Apr; 18 (2): 235–51.
5. Landes X. How Fair Is Actuarial Fairness? J Bus Ethics [Internet]. 2015; 128 (3): 519–33. Available from: http://search.ebscohost.com/login.aspx?direct=true&db=bth&AN=102426091&site=eds-live
6. Laniado-Laborin R. Smoking cessation intervention: an evidence-based approach. Postgrad Med. 2010 Mar; 122 (2): 74–82